Leon, Raymond NEW YORK STATE DEPARTMENT OF HEALTH
OFFICIAL BURIAL (OR REMOVAL) PERMIT
tgr This Permit can be signed only by the Local Registrar (Deputy or subregistrar) of the Primary Registration District (Town,
Village, or City) in which the death occurred after the FILING and acceptance of a CORRECT AND COMPLETE C RTIFICATE OF
DEATH, LEGIBLY WRITTEN IN DURABLE BLACK INK. Z
, Town, Village Register {oUUUU ,
Dist. No. :576/ Cou a.A1,4J ,�, / or City
(If city, give street address)
Name of deceased Veteran
(If veteran, give name of War)
Ingle, married, widowed, 7.1
.yy
Sex *4.20_.--- or divorced (write the word) Date of Death N-27 .
/ . 7 19 7..
Age 7/ Ye s Mo the Days Birthplace
Cause of Death • p-e.1,-.4....\47-:0:79t•-e--(A.
Certificate was signed by.... . .. . M.D.
Address C t Arta;�r
Place of Burial Removal {
( .. ..
;If body is to t porartl} , fi ) space aterj
cemetery �j Date of Burial 19 fi'
If body is to he temporarily hel , fi 1 in space later)
The CERTIFICATE OF DEATH containing the above stated particulars, having been presented to me, after careful examination, the
same appearing to be COMPLETE, CORRECT, AND SATISFACTORY AS REQUIRED BY LAW, I have accepted the same for registra-
ion, have a orded it in my Local Recor with the above stated Registered Number and on the basis;reof I HERE YGRANT A
PERMIT / 7 SiVi /i
:he to hold temporarily and . the ody
(Undertaker r e so having charge of cor ) (fi7Vemov , or over is, dispose of (stole how))
)ated �.,; // 19.. (Signed) ''``1r
Local"State
This•Permit is suf tcient for the Removal (and Interment or Cremation)of a body to any part of th State (sub(S.PPY
to local cemetery or
)they regulations), unless removal is by common carrier, in which case a Transit Permit (VS No. 62) is required.
FORM Vs. 61. IREV. 6/631 13A2.323)
ENDORSEMENT OF SEXTON OR PERSON IN CHARGE
OF PREMISES ON WHICH INTERMENTS OR
CREMATIONS ARE MADE
9
Date of "'/4/��'`'• l'-‘ was -"-:// 19 7
(Interment or Gremar,iaa1
(Name of Cemetery, Crematorium, etc.)
/-yFllo ff
Section Lot No. �i Grave No.
(Signed) 441' d :, ,- ---5-1.,/
l , (Person in Charge)
]
Address 7-( ''7 e'er` r___ / ) .
Person in charge must return this Permit to the Registrar
of his District within SEVEN (7) DAYS from above date. If no
person is in charge, the FUNERAL DIRECTOR or UNDER-
TAKER MUST SIGN ABOVE STATEMENT, write across the
face of the Permit the words "No person in charge," and
FILE PERMIT WITHIN THREE (3) DAYS with the Registrar
of District in which cemetery is located.
SEXTONS, FUNERAL DIRECTORS and UNDERTAKERS
violating the law relative to the return of permits are liable to
a penalty of NOT LESS THAN FIVE DOLLARS NOR MORE
THAN FIFTY DOLLARS FOR THE FIRST OFFENSE. The
law will be enforced. Local Registrars are required, under
penalty, to report violations thereof.